Correspondence
Transfusion in Pediatric Intensive Care Units
N Engl J Med 2007; 357:301-302July 19, 2007
- Article
To the Editor:
Lacroix et al. (April 19 issue)1 report that a restrictive transfusion strategy (a hemoglobin threshold of 7 g per deciliter) is as safe as a liberal strategy (a hemoglobin threshold of 9.5 g per deciliter) in pediatric patients in the intensive care unit whose condition is clinically stable. With regard to long-term safety, however, the risk of disease transmission is unquantifiable, and for this reason, the reduction in the number of transfusions is an important end point. We note that 14% of patients in the restrictive-strategy group and 37% in the liberal-strategy group had more than one blood transfusion and that the target range for hemoglobin was 1.5 to 2.5 g higher than the initial hemoglobin thresholds in both groups. Considering that patients with acute blood loss and hemodynamic instability were excluded, we suggest that especially in patients weighing less than 10 kg, this post-transfusion target is inadequate. Once the decision has been made to expose a patient to a donor unit, an adequate volume from that unit should be transfused initially, thus reducing the risks entailed in a requirement for a second or subsequent transfusion.
1 ReferencesNiamh P. Conlon, F.C.A.R.C.S.I.
Donal Ryan, F.C.A.R.C.S.I.
Our Lady's Hospital for Sick Children, Dublin 12, Ireland
tallniamh@hotmail.com 1
Lacroix J ,Hebert PC ,Hutchison JS , et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007;356:1609-1619
Full Text | Web of Science | Medline
To the Editor:
We recently surveyed practices regarding perioperative blood transfusion among members of the Association of Paediatric Anaesthetists in the United Kingdom. Of 234 respondents (59% of those surveyed), 58% reported that they were performing transfusions at hemoglobin thresholds that were lower than thresholds 5 years previously. The most common reasons given by respondents were evidence of the benefit of restrictive transfusion strategies in adults and an increased awareness of the risks of transfusion.
On the basis of the responses to a series of scenario-based questions, we found that the hemoglobin threshold for transfusion varied widely (from 5 to 12 g per deciliter) but averaged 7.6 g per deciliter for a patient with post-tonsillectomy hemorrhage. Even among neonates born prematurely who were undergoing elective inguinal hernia repair — a group of patients in whom a higher hematocrit is traditionally preferred1 — the mean hemoglobin threshold for preoperative transfusion was 8.1 g per deciliter.
It seems that the conclusions from earlier studies attesting to the safety of lower transfusion thresholds in critically ill adults have already been incorporated into the practice of pediatric anesthetists in the United Kingdom. Large studies such as that of Lacroix et al. support the change in perioperative transfusion practice that is already occurring in the United Kingdom.
1 ReferencesMonica Trivedi, M.B., B.S., F.R.C.A.
Liam Brennan, M.B., B.S., F.R.C.A.
Addenbrooke's Hospital, Cambridge CB2 2QQ, United Kingdom
monicatrivedi@doctors.org. uk 1
Cote CJ ,Zaslavsky A ,Downes JJ , et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy: a combined analysis. Anesthesiology 1995;82:809-822
CrossRef | Web of Science | Medline
Author/Editor Response
While conducting our study, we did not collect data on delayed complications of transfusions. Most transfusion reactions are acute.1 Late infectious problems that can be attributed to red-cell transfusions are infrequent in Canada, where the incidence of human immunodeficiency virus infection transmitted from a donor is less than 1 case per 4.7 million transfusions.2 The frequency of a delayed hemolytic transfusion reaction is 1 per 255,000.2 The overall incidence of long-term complications of transfusion is so low that it should not change the conclusion drawn from our study.
The target range for the hemoglobin level after red-cell transfusions was 1.5 to 2.5 g per deciliter higher than the initial threshold in both groups in our study. This target range was chosen to ensure that the difference in the hemoglobin level between the two groups would be large enough to be clinically significant. The conclusion drawn from the study applies to the threshold (7 rather than 9.5 g per deciliter), not to the target range. We agree with Conlon and Ryan that an adequate volume should be transfused initially, thus reducing the requirement for subsequent transfusion. This is why we adopted a 1-unit-per-transfusion strategy in the study, which meant that larger patients did not receive more than 1 unit per transfusion even when more blood would have been required to reach the target range; partial 75-ml units from the same donor were frequently used in smaller patients who required multiple transfusions.
Trivedi and Brennan state that in their survey of British anesthetists, the average red-cell transfusion chosen by the respondents for a child with post-tonsillectomy hemorrhage was 7.6 g per deciliter. It would be nice to know which hemoglobin threshold they actually use, because there can be a huge difference between stated and observed practice patterns.3
3 ReferencesJacques Lacroix, M.D.
Marisa Tucci, M.D.
France Gauvin, M.D., M.Sc.
Université de Montréal, Montreal, QC H3C 3J7, Canada
jacques_lacroix@ssss.gouv. qc. ca 1
Gauvin F ,Lacroix J ,Robillard P ,Lapointe H ,Hume H . Acute transfusion reactions in the pediatric intensive care unit. Transfusion 2006;46:1899-1908
CrossRef | Web of Science | Medline2
Infectious Diseases and Immunization Committee, Canadian Paediatric Society 3
Desmet L ,Lacroix J . Transfusion in pediatrics. Crit Care Clin 2004;20:299-311
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Alessandro Menotti, Mariapaola Lanti. (2008) An Italian Chart for Cardiovascular Risk Estimate Including High-Density Lipoprotein-Cholesterol. Disease Management & Health Outcomes 16:3, 183-197
CrossRef
